Upper eyelid rotation ﬂap for reconstruction of medial canthal defects Daniel S. Behroozan, MD,a and Leonard H. Goldberg, MD, FRCPa,b Houston, Texas M edial canthal defects resulting from cancer canthal defects using a superiorly based eyelid rota- resection after Mohs micrographic surgery tion ﬂap from a contiguous cosmetic subunit with present challenging reconstruction dilem- skin of identical color, texture, and thickness. mas. In fact, medial canthal reconstruction has been controversial because of the time-honored method OPERATIVE TECHNIQUE of second-intention healing in wound management Key features that must be identiﬁed before exe- of this area.1 Yet, small flaps and grafts for repair of cution of this repair technique include size, depth, cutaneous medial canthal defects may result in a and location of the defect, and whether the lacrimal quicker healing process with excellent cosmetic re- duct system has been damaged by tumor excision. sults. The main difficulties of reconstruction of the Indications for upper eyelid rotation are similar to medial canthal region are the lack of local availability those indicated for consideration of second-inten- of similar thin eyelid skin, and the concavity of the tion healing; namely, lesions less than 1.5 cm that do defect to be repaired. not involve the upper eyelid.4 Laxity of the upper The area of the medial canthus includes the free eyelid skin is the essential component for rotating tissue margins of the upper and lower eyelids, the tissue from the upper eyelid into the recipient defect bony attachments of the medial canthal tendon, the site. The flap is considered practical for patients with lacrimal puncta, and arteriovenous and neural bun- superficial to moderately deep wounds that do not dles that supply and innervate the region. The sacrifice the lacrimal apparatus. literature describes a multitude of surgically complex The procedure is performed under local anesthe- and intricate reconstruction methods including eye- sia. The defect at the medial canthal region is lid myocutaneous transposition flaps, glabellar flaps, measured and a ﬂap of adequate size is marked at cheek flaps, V-Y advancement flaps, and skin grafts the lower margin of the eyebrow on the adjacent for repair of defects of the medial canthus.2-6 upper eyelid (Figs 1 and 2). The flap to defect size Although these reconstructive options represent ratio should be 3:1 to 4:1 to ensure adequate blood tested and widely used choices for medial canthal supply across the flap. An incision is then made restoration, they are limited in that these techniques through the skin into the subcutaneous tissue of the often provide a less than ideal color or texture upper eyelid below the eyebrow to facilitate move- match, provide tissue that is either too thick or too ment of the flap into the recipient site (Fig 3). The thin, or place incisions that cross aesthetic units and flap is undermined and elevated, with the fulcrum boundaries. for rotation at the medial canthal tendon, and rotated We describe a novel ﬂap that is conceptually medially into the defect. A skin hook may facilitate simple to design and execute for the repair of medial proper placement of the flap and determines if there is enough donor skin to fill the defect (Fig 4). Subcutaneous layers of absorbable sutures are usu- From DermSurgery Associatesa and the Department of Medicine ally not necessary as there is no tension on the flap. (Dermatology), University of Texas, MD Anderson Cancer The flap is sutured using cutaneous 6-0 nonabsorb- Center.b Funding sources: None. able sutures in either an interrupted or running Conflicts of interest: None identified. fashion. The secondary defect below the eyebrow Reprint requests: Leonard H. Goldberg, MD, FRCP, DermSurgery is closed by lifting the eyelid skin to its new position Associates, 7515 Main, Suite 240, Houston, TX 77030. E-mail: at the lower border of the eyebrow (Fig 5). When firstname.lastname@example.org. rotating upper eyelid skin, a dog-ear is taken across J Am Acad Dermatol 2005;53:635-8. 0190-9622/$30.00 the bridge of the nose within relaxed skin tension ª 2005 by the American Academy of Dermatology, Inc. lines. This dog-ear may be avoided by using the doi:10.1016/j.jaad.2005.03.024 halving technique of suturing two sides of unequal 635 636 Behroozan and Goldberg J AM ACAD DERMATOL OCTOBER 2005 Fig 1. Medial canthal defect. Fig 3. Rotation of ﬂap into donor site. Fig 2. Skin marking delineating the planned eyelid rota- Fig 4. Use of skin hook to ensure adequate donor tissue tion ﬂap. for rotation. length. Finally, a bolster dressing may be used to lack of similar skin in the vicinity. As a result, second- hold the flap down securely into the concave sur- intention healing is often used as a default. The ﬂap face. The 1-week (Fig 6) and 4-week (Fig 7) follow- we describe presents a simple and relatively easy up results are shown. option for repair of superﬁcial to moderately deep defects that do not compromise the lacrimal appa- DISCUSSION ratus. Donor skin for medial canthal repairs includes The medial canthus is an area that has been a the glabella and the adjacent upper aspect of the historically challenging location for postoperative cheek; however, both of these donor sites provide repair because of the concavity of the area and the skin that is thicker than that of the medial canthal J AM ACAD DERMATOL Behroozan and Goldberg 637 VOLUME 53, NUMBER 4 Fig 5. Closure of secondary defect by lifting eyelid skin to its new position at the lower border of the eyebrow. Fig 7. Four week follow-up results. A full-thickness skin graft is an option that is useful for larger defects and especially in younger patients with superﬁcial defects whose lack of upper eyelid skin laxity precludes the use of rotation ﬂaps Fig 6. One week follow-up results. as a reparative choice. Skin may be harvested from the retroauricular, supraclavicular, or often the op- posite upper eyelid. Disadvantages of full-thickness region. Given the laxity of upper eyelid skin in well grafting includes the need for a donor site resulting in selected patients described above and the vascularity a secondary wound, possibilities of poor graft take, of eyelid skin, the upper eyelid rotation ﬂap is an poor color and texture match at the recipient site, excellent option for medial canthal repair with little and the need for a bulky and prolonged bolster or no tension. dressing for at least 1 week. Second-intention healing is a time-honored The use of ﬂaps, the most popular of which have method of healing that is especially useful for older historically been from the glabellar region, offer patients with loose skin. Contracture and healing of good color and texture match to the medial canthal defects is often expected in 4 to 6 weeks and results area. Yet, this ﬂap is limited by that fact that it is are often excellent with lack of postoperative pain inherently thicker skin from a second cosmetic unit and infections. Further advantages of this technique that is often bulky and distorts the naturally concave are in its simplicity and lack of need for further shape of the medial canthus. In addition, secondary surgical manipulation of tissue for reparative needs debulking and pedicle takedown procedures are especially in a growingly elderly population with often needed. cutaneous neoplasms. Disadvantages include length The upper eyelid rotation ﬂap described above of time for complete healing and need for meticulous does have limitations in that defects that are partic- wound care and bulky bandages for a prolonged ularly large or deep may not be amenable to this period that is often frustrating for patients. In addi- reparative technique. Canthal webbing may result if tion, healing may lead to pulling of the lid anteriorly there is not enough upper eyelid donor skin for off the globe as a result of wound contraction leading rotation into a defect at hand. Rotation puckers may to ectropion formation, an elevation of the canthus to appear toward the caruncle and may be routinely a higher position as a result of scar formation, or excised during reconstructive repair. However, be- both. These complications may result in the need for cause of the thin and loose skin present at the inner a second reconstructive procedure at a later date for canthus, the authors have found that puckers are surgical correction. very forgiving and often stretch out on their own in 638 Behroozan and Goldberg J AM ACAD DERMATOL OCTOBER 2005 this region. In addition, the medial canthus is a thickness. Evaluation of defect and upper eyelid concave surface, and the ﬂap should have a bolster laxity will determine if this ﬂap is feasible in a dressing applied for 1 week to hold the ﬂap in place, selected patient, and may provide the dermatologic which may be disconcerting to some patients. surgeon with an option other than prolonged sec- Basting sutures are not routinely placed as the bolster ond-intention healing, grafting, or more intricate dressing stays in place for 1 week by which time the ﬂaps leading to rapid and outstanding results for base of the ﬂap has ﬁrmly adhered to the underlying his/her patients. tissue. Nonetheless, it would not be incorrect to place basting sutures if the surgeon thought they would be of beneﬁt in a particular case. Yet, the REFERENCES upper eyelid rotation ﬂap is from the same cosmetic 1. Lowry JC, Bartley GB, Garrity JA. The role of second-intention subunit as the defect for medial canthal reconstruc- healing in periocular reconstruction. Ophthal Plast Reconstr tion; thus, it has the same skin texture, color, and Surg 1997;13:174-88. thickness as the original defect, resulting in excellent 2. Jelks GW, Glat PM, Jelks EB, Longaker MT. Medial canthal reconstruction using a medially based upper eyelid myocuta- cosmetic outcomes. Patients must be individually neous flap. Plast Reconstr Surg 2002;110:1636-43. evaluated and selected to ensure that there is ade- 3. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic quate excess eyelid skin to optimize healing and approach. Plast Reconstr Surg 1993;91:1017-24. anatomic restoration of the medial canthus. 4. Moy RL, Ashjian A. Periorbital reconstruction. J Dermatol Surg In summary, we believe that the upper eyelid Oncol 1991;17:153-9. 5. Anderson RL, Edwards JJ. Reconstruction by myocutaneous rotation ﬂap is a reliable, technically practical, and eyelid flaps. Arch Ophthalmol 1979;97:2358-62. aesthetic method for medial canthal repair that 6. Rodriguez RL, Zide BM. Reconstruction of the medial canthus. provides superb color, texture match, and tissue Clin Plast Surg 1988;15:255.
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